This proposal is a response to PAS-19-241, Stimulating Urology Interdisciplinary Team Opportunity Research, the aim of which is to promote innovative, high-quality, interdisciplinary research relevant to the NIDDK. Importantly, this PAS and a prior workshop identified psychosocial factors in women with urinary incontinence as an important knowledge gap. To this end, we bring together experts from behavioral sciences, urology, molecular pathology, and regenerative medicine to explore further our initial findings that socially subordinate female monkeys do not respond as well to cell therapy for urinary incontinence as their dominant counterparts. We now propose a more comprehensive approach to assess (a) sympathetic nervous system (SNS) arousal, hypothalamic-pituitary-adrenal (HPA) activation, and impaired ovarian function in socially housed monkeys; and (b) the likely pathways by which social subordination stress affects structural and functional regeneration within the urinary sphincter. Two likely pathways through which social subordination stress may modulate these processes are cortisol and SNS effects on tissue and cell damaging inflammation and estrogen-deficiency-associated inhibition of cell mobilization. These processes are not mutually exclusive and may involve the CXCL12/CXCR4 signaling pathway. Based on our previous studies and the published literature, our central hypothesis is that psychosocial stress inhibits the regenerative effects of cell therapy by reducing the mobilization of tissue healing bone marrow progenitor cells, and increasing the presence of hematopoietic tissue damaging inflammatory cells in the urinary sphincter. This hypothesis will be tested in a prospective, randomized, nonhuman primate preclinical trial using our well-characterized female cynomolgus monkey model of psychosocial stress due to social subordination, and our model of intrinsic urinary sphincter deficiency. Our Specific Aims are to determine the effect of social status on: 1) the structural (cellular, acellular, vascular, innervation) and functional (urinary sphincter and bladder) effects of autologous skMPC therapy in female primates with ISD; 2) The injected lenti-M-cherry+ skMPC cell retention in, and lenti GFP+ labeled bone marrow cell mobilization to, the urinary sphincter of dominant and subordinate monkeys; 3) The effect of social subordination stress on abundance and polarization of inflammatory cells and associated molecules in the urinary sphincter; and 4) Whether social status effects on cell therapy-induced tissue regeneration are mediated by behavioral stress, SNS, HPA, or ovarian function. The results of this translational research will promote understanding of limitations and potential future regenerative medicine strategies for women with urinary incontinence.